A Randomized Controlled Trial of Holistic Neuropsychologic Rehabilitation After Traumatic Brain Injury

Cicerone KD, Mott T, Azulay J, Sharlow-Galella MA, Ellmo WJ, Paradise S, Friel JC. A randomized controlled trial of holistic neuropsychologic rehabilitation after traumatic brain injury.

Objective

To evaluate the effectiveness of comprehensive, holistic neuropsychologic (NP) rehabilitation compared with standard, multidisciplinary rehabilitation for people with traumatic brain injury (TBI).

Design

Randomized practical controlled trial.

Setting

Postacute brain injury rehabilitation center within a suburban rehabilitation hospital.

Participants

Participants with TBI were recruited from clinical referrals and referrals from the community. Sixty-eight participants who met inclusion criteria were randomly allocated to treatment conditions. Most participants (88%) had sustained moderate or severe TBI, and greater than half (57%) were more than 1 year postinjury at the beginning of treatment.

Interventions

Treatment was conducted 15 hours per week for 16 weeks. Standard neurorehabilitation consisted primarily of individual, discipline specific therapies (n=34). Intensive cognitive rehabilitation emphasized the integration of cognitive, interpersonal, and functional interventions within a therapeutic environment (n=34).

Main Outcome Measures

Primary outcomes were the Community Integration Questionnaire (CIQ) and Perceived Quality of Life scale (PQOL). Secondary outcomes included NP functioning, perceived self-efficacy, and community-based employment.

Results

NP functioning improved in both conditions. Intensive cognitive rehabilitation participants showed greater improvements on the CIQ (effect size [ES]=0.59) and PQOL (ES=0.30) as well as improved self-efficacy for the management of symptoms (ES=0.26) compared with standard neurorehabilitation treatment. These gains were maintained at the 6-month follow-up. Standard neurorehabilitation participants showed improved productivity at the 6-month follow-up associated with the need for continued rehabilitation.

Conclusions

Improvements seen after intensive cognitive rehabilitation may be related to interventions directed at the self-regulation of cognitive and emotional processes and the integrated treatment of cognitive, interpersonal, and functional skills. The results show the effectiveness of comprehensive holistic NP rehabilitation for improving community functioning and quality of life after TBI compared with standard rehabilitation.     

A trial of neuropsychologic rehabilitation in mild-spectrum traumatic brain injury

OBJECTIVE: To test the effectiveness of a neuropsychologic rehabilitation program consisting of psychotherapy and cognitive remediation in the treatment of the affective and neuropsychologic sequelae of mild-spectrum traumatic brain injury (TBI). DESIGN: Single-blind randomized, wait-listed controlled trial, with repeated measures and multiple baselines. SETTING: Outpatient clinic in northern New Jersey. PARTICIPANTS: Twenty persons with persisting complaints after mild and moderate TBI (11 in treatment group, 9 controls). INTERVENTIONS: The experimental group received both 50 minutes of individual cognitive-behavioral psychotherapy and 50 minutes of individual cognitive remediation, 3 times a week for 11 weeks. The control group was wait-listed and received treatment after conclusion of follow-up. MAIN OUTCOME MEASURES: Symptom Check List-90R General Symptom Index, plus scales of depression, anxiety, coping, attention, and neuropsychologic functioning. RESULTS: Compared with the control group, the treatment group showed significantly improved emotional functioning, including lessened anxiety and depression. Most significant improvements in emotional distress were noted at 1 month and 3 months posttreatment. Performance on a measure of divided auditory attention also improved, but no changes were noted in community integration scores. CONCLUSIONS: Cognitive behavioral psychotherapy and cognitive remediation appear to diminish psychologic distress and improve cognitive functioning among community-living persons with mild and moderate TBI.     

Outcome of a comprehensive neurorehabilitation program for patients with traumatic brain injury

OBJECTIVE: To evaluate the outcome of a comprehensive neurorehabilitation program compared with that of conventional clinical care and rehabilitation for patients with traumatic brain injury (TBI). DESIGN: Nonrandomized, controlled trial with a 2-year follow-up. SETTING: Nationwide rehabilitation center and level I trauma center, both in Finland. PARTICIPANTS: We studied 19 consecutive adults with a significant TBI who underwent a comprehensive neurorehabilitation program and 20 control patients who received conventional rehabilitation referred by physicians in the general health care system. The outcome of the control patients was not known before the selection. The groups were similar in age, sex, education, injury severity (assessed on the Glasgow Coma Scale, radiologic and neuropsychologic findings, neurosurgical interventions), time from the injury, and preinjury employment status. INTERVENTIONS: A postacute, intensive, interdisciplinary, 6-week rehabilitation program for TBI patients who are considered to have adequate potential to achieve productivity by this means; focus on neuropsychologic rehabilitation and psychotherapy with vocational interventions and follow-up support. MAIN OUTCOME MEASURE: Status of productivity, judged as productive (defined as working, studying, or participating in volunteer activities) or nonproductive, evaluated on questionnaires filled in by patients and their significant others at the time of follow-up evaluation. RESULTS: At follow-up, 89% of the treated patients were productive compared with 55% of the controls. The rehabilitation program was significantly predictive of the productive status at follow-up (odds ratio=6.96; 95% confidence interval, 1.26-38.44; P=.017). Other factors did not explain the better productivity of the treatment group. Two neuropsychologist-evaluators, who were blind to the rehabilitation history of patients and to each other's evaluations, were perfectly consistent in their classification of patients' productivity statuses. CONCLUSIONS: The findings support the proposition that comprehensive neuropsychologically oriented rehabilitation programs can improve psychosocial functioning in terms of productivity in postacute patients with moderate to severe TBI. Additional larger controlled studies are needed to establish the efficacy of TBI rehabilitation interventions.     

The Community Integration Questionnaire revisited: an assessment of factor structure and validity.

OBJECTIVE: To investigate the factor structure and concurrent validity of the Community Integration Questionnaire (CIQ), using a large sample of persons with traumatic brain injury (TBI). DESIGN: Principal components analysis with varimax rotation was performed on CIQ items completed through interview with patients at 1 year after injury. Correlational analyses compared CIQ scores to scores on other widely used outcome measures. SETTING: Outpatient clinics affiliated with four TBI Model System rehabilitation centers funded by the National Institute on Disability and Rehabilitation Research. PARTICIPANTS: Three hundred twelve patients with medically documented TBI who were enrolled in the TBI Model Systems Project. The majority of patients were Caucasian males with severe TBI. MAIN OUTCOME MEASURES: CIQ; Functional Independence Measure (FIM); Functional Assessment Measure (FAM); Disability Rating Scale (DRS). RESULTS: Three factors emerged: Home Competency, Social Integration, and Productive Activity. The financial management item was moved from Social Integration to Home Competency, and the travel item was moved from Productive Activity to Social Integration. Each CIQ scale score showed significant correlations in the expected direction with the FIM+FAM and DRS items. CONCLUSIONS: The results provide further evidence for the validity of the CIQ and improve the scoring system. The factor structure is clinically and theoretically meaningful. The subscale and total scores show significant relationships with other widely used measures of outcome. Future research should focus on increasing the range of questions, accounting for changes from preinjury functioning, and obtaining normative data on the new factors.     

A comparison of substance abuse and violence in the prediction of long-term rehabilitation outcomes after traumatic brain injury

OBJECTIVE: To determine the relative contributions of substance abuse history and violent etiology to the prediction of outcomes for individuals who sustained a traumatic brain injury (TBI) requiring inpatient rehabilitation. DESIGN: Longitudinal study of outcomes 1 year postdischarge from rehabilitation. SETTING: Specialized TBI acute rehabilitation unit. PARTICIPANTS: Three hundred fifty-one individuals consecutively admitted for rehabilitation. INTERVENTIONS: Gathered data from patients' medical records (including etiology of injury, initial Glasgow Coma Scale scores, and FIMtrade mark instrument scores at discharge), demographic details, and history of substance abuse; phone and mail survey data from individuals (Satisfaction with Life Scale [SWLS]; Community Integration Questionnaire [CIQ]). MAIN OUTCOME MEASURES: CIQ and SWLS; relative contributions of injury etiology, demographic and injury-related dependent variables, and substance abuse history to predictive model. RESULTS: Almost 80% of persons with injuries from violence-related causes had a history of substance abuse. Substance abuse was found to contribute to the prediction of life satisfacton and productivity, while violent etiology was not a significant contributor to predictive models. CONCLUSION: Substance abuse history proved to be a strong predictor of long-term outcomes, while violent etiology of injury was less influential. The results of this study emphasize the need to include substance abuse history in all studies of outcomes after TBI, and to increase prevention efforts to limit the effects of such a history.     

Early versus later admission to postacute rehabilitation: impact on functional outcome after traumatic brain injury

OBJECTIVE: To examine the impact of participation in a postacute community reentry program on functional outcome after traumatic brain injury (TBI). DESIGN: Cohort, nonrandomized, intervention study. Pretest-posttest, follow-up design. SETTING: Nonprofit outpatient community reentry program affiliated with an inpatient rehabilitation hospital. PARTICIPANTS: Three groups of persons with moderate to severe TBI differing in length of time between injury and admission. The first group entered postacute rehabilitation within 6 months of injury (n=115); the second group, between 6 and 12 months (n=23); and the third group, greater than 12 months (n=29). INTERVENTIONS: Persons with TBI participated in a postacute community reentry program (average, 4.3mo) that emphasized (1) teaching compensatory strategies to address residual cognitive deficits; (2) arranging environmental supports to maximize functioning; (3) counseling and education to address personal and family adjustment and to improve accurate self-awareness; and (4) transition from simulated activities in the clinic to productive activities in the community. MAIN OUTCOME MEASURES: Disability Rating Scale, Supervision Rating Scale, and the Community Integration Questionnaire. RESULTS: All groups showed improvements between admission and discharge on measures of overall disability, independence, home competency, and productivity, and these gains were maintained at follow-up. For the group beginning postacute rehabilitation the earliest (<6mo postinjury) independence continued to improve after discharge. Community integration total score and home competency also continued to improve even after discharge. CONCLUSIONS: The results point toward the effectiveness of postacute rehabilitation in improving functional outcome after TBI even for persons who have reached stable neurologic recovery at 12 or more months postinjury.     

Comparing functional status and community integration in severe penetrating and motor vehicle-related brain injuries

Wertheimer JC, Hanks RA, Hasenau DL. Comparing functional status and community integration in severe penetrating and motor vehicle-related brain injuries.

Objective

To examine the functional status of persons surviving a severe penetrating traumatic brain injury (TBI) resulting from a gunshot wound who require inpatient rehabilitation.

Design

Data were collected prospectively at 4 different time periods: rehabilitation admission and discharge and year 1 and year 2 postinjury.

Setting

Rehabilitation hospital within a Traumatic Brain Injury Model System.

Participants

Forty-five persons with severe penetrating brain injury and 45 persons involved in a motor vehicle crash (MVC).

Interventions

Not applicable.

Main Outcome Measures

Disability Rating Scale (DRS), FIM instrument, and Community Integration Questionnaire (CIQ).

Results

Results indicated functional improvements for both the penetrating and motor vehicle severe TBI groups on the DRS and the FIM from rehabilitation admission to discharge. Follow-up data at 1 and 2 years postinjury revealed continued improvements on the DRS and FIM measures for both groups, with the greatest improvement in recovery during the first year. In addition, improved community reintegration emerged between 1 and 2 years postinjury for both groups, as measured by the CIQ. There was a small significant difference on the outcome measures between the 2 groups in the course of their recovery.

Conclusions

Persons who survive severe penetrating brain injuries and who require inpatient rehabilitation may show continuing improvement in functioning over time. For persons receiving inpatient rehabilitation services, initial improvement is most likely to occur during the hospital stay and continue postinjury, with the largest improvement in the first year after injury. Community reintegration can also be expected over time. One can expect similar outcomes for individuals who sustain a severe penetrating brain injury and a severe brain injury ensuing from an MVC.     

Etiology of traumatic brain injury: characterization of differential outcomes up to 1 year postinjury

OBJECTIVE: To characterize outcomes after traumatic brain injury (TBI) resulting from vehicular crashes, violence, falls, or other causes. DESIGN: Prospective, multicenter, longitudinal. SETTING: Seventeen Traumatic Brain Injury Model Systems. PARTICIPANTS: A total of 1,170 individuals with moderate to severe TBI with data from initial medical and rehabilitation stays and 1-year follow-up. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: At rehabilitation discharge, FIM instrument, Disability Rating Scale (DRS), and Rancho Los Amigo Levels of Cognitive Functioning Scale. At 1 year postinjury, FIM, DRS, Community Integration Questionnaire (CIQ), employment, residence, marital status, and seizure occurrence. RESULTS: The 4 etiology groups could be distinguished based on premorbid characteristics. Severity of injury indices indicated that individuals in vehicular crashes showed a trend toward incurring more severe injuries than the other 3 groups. At rehabilitation discharge, there were no functional differences between groups. At 1 year postinjury, the groups could be differentiated: individuals in violence-related TBI had higher unemployment rates and lower CIQ scores; persons in vehicular crashes reported the best functional and psychosocial outcomes; and individuals in the falls and other groups had outcomes lying between the vehicular and violence groups. CONCLUSION: This study elucidated important differences between persons with violence-related TBI and those with non-violence-related TBI. Further research is needed to find effective interventions to address these differences.     

Relationship of caregiver and family functioning to participation outcomes after postacute rehabilitation for traumatic brain injury: a multicenter investigation

Sander AM, Maestas KL, Sherer M, Malec JF, Nakase-Richardson R. Relationship of caregiver and family functioning to participation outcomes after postacute rehabilitation for traumatic brain injury: a multicenter investigation.ObjectiveTo investigate the contribution of caregiver emotional functioning and family functioning to participation outcomes after postacute rehabilitation for traumatic brain injury (TBI).DesignProspective cohort study.SettingThree postacute comprehensive-integrated postacute rehabilitation programs associated with National Institute on Disability and Rehabilitation Research–funded TBI Model Systems Centers.ParticipantsPersons with medically documented TBI (N=136; 57% with severe TBI, 12% moderate, 31% mild), primarily men and 69% white.InterventionsNot applicable.Main Outcome MeasuresCommunity Integration Questionnaire and Craig Handicap Assessment and Reporting Technique (CHART).ResultsAfter accounting for age, education, sex, and race/ethnicity, there was a significant interaction between caregiver emotional functioning and time since injury for CHART Occupation and Social Integration Scale scores. Better emotional functioning in caregivers was associated with greater occupation and social integration outcomes for persons who entered the postacute rehabilitation program within 6 months of injury, but not for those >6 months postinjury. There was no relationship of family functioning to participation outcomes, and no interaction between family functioning and time since injury.ConclusionsCaregiver distress should be accounted for in studies investigating the effectiveness of postacute rehabilitation after TBI. Screening of caregivers early during postacute rehabilitation can target those who need assistance to improve their support of the person with TBI.     

Residential and home-based postacute rehabilitation of individuals with traumatic brain injury: a case control study

OBJECTIVES: To compare the outcomes of severely brain-injured individuals treated in a postacute residential rehabilitation program with a matched sample of individuals receiving limited services in their homes or on an outpatient basis. DESIGN: Controlled study using a matched design in a before-and-after trial and a 1-year follow-up trial. SETTING: A postacute community-based residential rehabilitation program or in the homes of patients. PATIENTS AND OTHER PARTICIPANTS: The treatment group included all persons admitted consecutively for rehabilitation to the postacute residential program over a 3-year period (n = 23). All subjects had severe traumatic brain injury. The comparison group was selected from the roster of a support group on the basis of a systematic matching procedure. Matching variables included gender, age, length of coma, time since injury, and level of disability. Subjects of the two groups were matched on an individual basis. MAIN OUTCOME MEASURES: A functional assessment instrument (modified Health andActivity Limitations Survey [HALS]) and the Community Integration Questionnaire (CIQ). RESULTS: Individuals with traumatic brain injury who received residential-based postacute rehabilitation displayed a statistically significant increase in functional abilities when compared with a traditional (home-based) service group. More specifically, treatment subjects showed significantly greater improvement in motor skills and cognitive abilities. Treatment subjects also showed greater improvement in community integration, although this may have been accounted for by initial group differences. CONCLUSIONS: Postacute rehabilitation appears to be effective in improving function for individuals with severe brain injury. Residential-based services appear to produce greater functional improvement, whereas home-based services are more effective at maintaining community integration.     

A comparison of acute and postdischarge predictors of employment 2 years after traumatic brain injury

OBJECTIVE: To examine whether adding postdischarge psychosocial predictors to premorbid and injury-related variables improved the capacity to predict employment 2 years after rehabilitation for traumatic brain injury (TBI). DESIGN: Data were collected prospectively at 6 and 24 months after discharge from rehabilitation. Logistic regression analyses examined predictors of employment status. SETTING: Inpatient and community TBI rehabilitation service attached to a major Australian teaching hospital. PARTICIPANTS: Fifty-five patients with TBI, aged 16 or older, who were consecutively admitted to a brain injury unit with complete longitudinal data and who agreed to participate in the study. INTERVENTION: Measured injury severity (Glasgow Coma Scale scores, posttraumatic amnesia); functional independence (Functional Assessment Measure cognitive subscale) at admission and discharge from rehabilitation; self-report of employment (premorbid, postdischarge); postdischarge psychosocial status at 6 months and 2 years (Community Integration Questionnaire, General Health Questionnaire, Trauma Complaints List, Overt Aggression Scale, Alcohol Use Disorders Inventory Test, Satisfaction with Life Scale). MAIN OUTCOME MEASURES: Employment status (employed, unemployed) was used to reflect vocational outcome. Predictor variables comprised premorbid work status, injury-related variables (age, injury severity), and postdischarge variables (employment, community integration, psychologic, cognitive status). RESULTS: Adding postdischarge predictors to premorbid and acute variables significantly improved the ability to predict work status 2 years after rehabilitation. Age at the time of injury, premorbid employment status, work status, and psychologic distress 6 months postdischarge were significant predictors of employment. CONCLUSIONS: It is important to consider postdischarge psychologic well-being, in conjunction with premorbid and acute factors, in vocational interventions after TBI.     

Course of functional improvement after stroke, spinal cord injury, and traumatic brain injury.

OBJECTIVE: To examine functional improvement patterns of persons with stroke, traumatic brain injury (TBI), and spinal cord injury (SCI). DESIGN: Statistical analysis of data from a multisite study evaluating rehabilitation outcomes. SETTING: Eight inpatient rehabilitation facilities. PARTICIPANTS: A total of 314 consecutive admissions of persons with stroke, SCI, and TBI who received acute medical rehabilitation between 1994 and 1998. INTERVENTION: Calibration of motor and cognitive items from the FIM instrument, grouping of cases by number of weeks of rehabilitation (length of stay [LOS] groups), and plotting of weekly averages across time. MAIN OUTCOME MEASURES: Weekly motor and cognitive functional status. RESULTS: With the exception of cognitive functioning for persons with SCI, LOS was related to initial functional status, with patients with greater disability having longer LOS (eg, initial motor status for persons with stroke was 48.3 for those with a 2-week stay, 36.8 for a 6-week stay, with the averages between decreasing monotonically). With the exception of cognitive gains for person with TBIs, the amount of functional gain during rehabilitation was essentially the same for all LOS groups (eg, the overall average total motor gain for persons with SCI is 22.3, with no patterns of increase or decrease across LOS groups); however, the rate of improvement in motor (but not cognitive) functioning differed across LOS groups, with patients with shorter stays having the greater rates of improvement (eg, the overall average weekly motor gain for persons with SCI was 3.6, with the averages by LOS group monotonically decreasing from 6.4 for those with 4-week stays to 2.7 for those with 9-week stays). CONCLUSIONS: When examined separately for persons grouped by LOS, functional status improved linearly during the rehabilitation stay, with differences in rate of improvement depending on initial functional status.     

Early cognitive status and productivity outcome after traumatic brain injury: findings from the TBI model systems

OBJECTIVE: To evaluate the contribution of early cognitive assessment to the prediction of productivity outcome after traumatic brain injury (TBI) adjusted for severity of injury, demographic factors, and preinjury employment status. DESIGN: Inception cohort. SETTING: Six inpatient brain injury rehabilitation programs. PARTICIPANTS: A total of 388 adults with TBI whose posttraumatic amnesia (PTA) resolved before discharge from inpatient rehabilitation. INTERVENTIONS: Administered neuropsychologic tests during inpatient stay on emergence from PTA. Follow-up interview and evaluation. Predictor measures also determined. MAIN OUTCOME MEASURE: Productivity status at follow-up 12 months postinjury. RESULTS: Multiple logistic regression analysis revealed that preinjury productivity status, duration of PTA, education level, and early cognitive status each made significant, independent contributions to the prediction of productivity status at follow-up. When adjusted for all other predictors, persons scoring at the 75th percentile on early cognitive status (less impaired) had 1.61 times greater odds (95% confidence interval [CI], 1.07-2.41) of being productive follow-up than those scoring at the 25th percentile (more impaired). Without adjustment, persons scoring at the 75th percentile had 2.46 times greater odds (95% CI, 1.77-3.43) of being productive at follow-up. CONCLUSIONS: Findings support the utility of early cognitive assessment by using neuropsychologic tests. In addition to other benefits, early cognitive assessment makes an independent contribution to prediction of late outcome. Findings support the clinical practice of performing initial neuropsychologic evaluations after resolution of PTA.     

The Persian Version of Community Integration Questionnaire in persons with multiple sclerosis: translation,reliability, validity,and factor analysis

Purpose: To culturally translate and validate the Community Integration Questionnaire (CIQ) in persons with multiple sclerosis (MS). Methods: After a forward–backward translation, 105 persons with MS completed the Persian versions of the CIQ and MS Quality of Life (MSQOL) questionnaires in the first visit. The CIQ was re-administered to a sample of 45 persons with MS 7–10 days after the first session. Test–retest reliability and internal consistency were assessed using intraclass correlation coefficient (ICC) and Cronbach’s α coefficient, respectively. Construct validity was assessed by measuring associations between subscales of the Persian CIQ (including Home Integration (HI), Social Integration (SI), and Productivity (P)) and MSQOL (including Physical and Mental Components). Dimensionality was assessed through two methods of corrected item-subscale correlation and factor analysis. Results: The acceptable level of test–retest reliability (ICC ≥0.70) was obtained for the Persian CIQ. However, Cronbach’s α coefficient of ≥0.70 was only seen for the HI. The correlations between the Persian CIQ and the Physical MSQOL were higher than those of Persian CIQ and the Mental MSQOL. The corrected item-subscale Spearman’s correlation coefficient of 0.40 was exceeded by most items of the HI and 2 items of P. A total of four factors were detected and similar to the results of item-subscale correlation, the most variability was seen for the items of SI which loaded on different factors. Conclusions: Persian CIQ seems to be a reliable and valid instrument for monitoring the level of community integration following rehabilitation in persons with MS. Some modifications need to be made in the SI of the Persian CIQ to improve extraction of information regarding community integration of persons with MS.

Implications for Rehabilitation

• The results on psychometric properties of the Persian Community Integration Questionnaire (CIQ) are comparable with the English and Spanish versions.

• Persian version of the CIQ appears to be a reliable and valid instrument to assess community integration in “clinical” and “research” settings of Persian-speaking Iranians with definite diagnosis of multiple sclerosis (MS).

     

Neuropsychologic and functional outcome after complicated mild traumatic brain injury

Kashluba S, Hanks RA, Casey JE, Millis SR. Neuropsychologic and functional outcome after complicated mild traumatic brain injury.

Objective

To investigate the extent to which neuropsychologic and functional outcome after complicated mild traumatic brain injury (TBI) parallels that of moderate TBI recovery.

Design

A longitudinal study comparing neuropsychologic and functional status of persons with complicated mild TBI and moderate TBI at discharge from inpatient rehabilitation and at 1 year postinjury.

Setting

Rehabilitation hospital with a Traumatic Brain Injury Model System.

Participants

Persons with complicated mild TBI (n=102), each with an intracranial brain lesion documented through neuroimaging and a highest Glasgow Coma Scale (GCS) score in the emergency department between 13 and 15, and 127 persons with moderate TBI.

Interventions

Not applicable.

Main Outcome Measures

FIM instrument, Disability Rating Scale, Community Integration Questionnaire, Wechsler Memory Scale logical memory I and II, Rey Auditory Verbal Learning Test, Trail-Making Test, Controlled Oral Word Association Test, Symbol Digit Modalities Test, Wisconsin Card Sorting Test, and block design.

Results

Few differences in neuropsychologic performance existed between the TBI groups. Less severely impaired information processing speed and verbal learning were seen in the complicated mild TBI group at rehabilitation discharge and 1 year postinjury. Despite overall improvement across cognitive domains within the complicated mild TBI group, some degree of impairment remained at 1 year postinjury on those measures that had identified participants as impaired soon after injury. No differences on functional ability measures were found between the TBI groups at either time period postinjury, with both groups exhibiting incomplete recovery of functional status at the 1-year follow-up.

Conclusions

When classifying severity of TBI based on GCS scores, consideration of a moderate injury designation should be given to persons with an intracranial bleed and a GCS score between 13 and 15.     

脑外伤患者的执行功能与社区融入的相关性分析

目的 调查脑外伤患者的执行功能与社区融入的关系,并探寻社区融入的主要影响因素。 方法 横断面研究脑外伤患者30例,记录其性别、年龄、教育年限、昏迷天数、生活状态和移动能力,使用执行功能失常问卷（DEX）与威斯康星卡片分类测验（WCST）评估执行功能,社区融入问卷（CIQ）评估社区融入情况。通过相关性分析和多重线性回归分析一般资料、生活状态、移动能力分级和执行功能与CIQ各项得分的相关性和独立影响因素。 结果 CIQ总分与WCST-RP评分（r=-0.47,P<0.01）、DEX评分（r=-0.44, P<0.01）、WCST-RPE评分（r=-0.41, P<0.05）呈负相关,与移动能力（r=0.39, P<0.05）呈正相关,与生活状态存在显著相关性（P<0.05）,执行功能（DEX评分和WCST-RP评分）是社区融入的独立影响因素。CIQ家庭融入得分与昏迷天数（r=-0.31, P<0.05）呈负相关,与生活状态存在显著相关性（P<0.05）,生活状态和昏迷天数是CIQ家庭融入得分的独立影响因素。CIQ社交融入得分与移动能力呈正相关（r=0.61, P<0.01）,与DEX评分（r=-0.39, P<0.05）、WCST-RP评分（r=-0.67, P<0.01）和WCST-RPE评分（r=-0.52, P<0.01）呈负相关,WCST-RP评分和移动能力是CIQ社交融入得分的独立影响因素。CIQ生产活动融入得分与DEX评分（r=-0.58, P<0.01）、WCST-RP评分（r=-0.42, P<0.05）和WCST-RPE评分（r=-0.38, P<0.05）呈负相关,执行功能（DEX评分和WCST-RP评分）是CIQ生产活动融入得分的独立影响因素。 结论 执行功能可独立影响社区融入,尤其在社交融入维度,执行功能有着至关重要的作用。     

Cognitive Behavioral Therapy,Self-Efficacy,and Depression in Persons with Chronic Pain

Chronic pain is a complex and often disabling condition compounded by depression and poor self-efficacy. The purpose of this evidence-based project was to explore the relationship of cognitive behavioral therapy (CBT)–focused groups with self-efficacy and depression in persons with chronic pain at an intensive interdisciplinary 3-week pain rehabilitation center (PRC). The project sample consisted of 138 persons admitted to a PRC and scoring ≥27 on the Center for Epidemiological Study Depression Scale (CES-D) and then completing the Pain Self-Efficacy Questionnaire (PSEQ). After completing the PRC program, including CBT-focused groups, discharge CES-D and PSEQ scores were analyzed. A comparison group of CES-D scores from 134 persons admitted to the PRC from a 9-month time period preceding the addition of the CBT-focused groups was also examined. There was a significant increase in self-efficacy after participation in the intensive pain rehabilitation program including CBT-focused groups. Patient groups both before and after introduction of CBT-focused groups showed the same rate of improvement on the depression scores, suggesting that persons who participated in CBT-focused groups improved equally compared with persons who did not participate in these groups. Ninety-three percent of the participants expressed satisfaction with the CBT groups. This evidence-based practice is well supported in the literature and can be implemented with knowledgeable staff and engaged stakeholders.     

Return to productive activity after traumatic brain injury: relationship with measures of disability, handicap, and community integration.

OBJECTIVES: To identify which factors are associated with successful return to productive activity (RTPA) 1 year after hospitalization with traumatic brain injury (TBI) and to examine the relations between successful RTPA and other measures of impairment, disability, handicap, and integration into the community. DESIGN: Prospective study with 1-year follow-up. SETTING: Level I trauma center. PARTICIPANTS: One hundred five respondents from a cohort of 378 adults hospitalized with TBI admitted between September 1997 and May 1998. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Return to productive work 1 year after injury; Disability Rating Scale (DRS); and Community Integration Scale (CIQ). RESULTS: Of the 105 participants, 72% achieved RTPA. Logistic regression showed an association between RPTA and the following factors: premorbid educational level, premorbid psychiatric history, violent mechanism of injury, discharge status after acute hospitalization, prior alcohol and drug use, and injury severity. Handicap and community integration at 1-year postinjury, as measured by subscales of the DRS and the CIQ, were also associated with RTPA. CONCLUSION: Premorbid and injury-related variables and measures of handicap and community integration were associated with RTPA at 1 year. To understand and effectively support vocational pursuits in the TBI population, future studies are needed to define further causality and origin of these relationships.     

Community integration after burn injuries

Evaluation of community integration is a meaningful outcome criterion after major burn injury. The Community Integration Questionnaire (CIQ) was administered to 463 individuals with major burn injuries. The CIQ results in Total, Home Integration, Social Integration, and Productivity scores. The purposes of this study were to determine change in CIQ scores over time and what burn injury and demographic factors predict CIQ scores. The CIQ scores did not change significantly from 6 to 12 to 24 months postburn injury. Home integration scores were best predicted by sex and living situation; Social Integration scores by marital status; and Productivity scores by functional outcome, burn severity, age, and preburn work factors. The data demonstrate that individuals with burn injuries have significant difficulties with community integration due to burn and nonburn related factors. CIQ scores did not improve over time but improvement may have occurred before the initial 6-month postburn injury follow-up in this study.